Abstract and Introduction

Introduction

Food allergies affect an estimated 15 million persons in the United States,[1] and are responsible for approximately 30,000 emergency department visits and 150–200 deaths each year.[2] Nearly half of reported fatal food allergy reactions over a 13-year period were caused by food from a restaurant or other food service establishment.[3] To ascertain the prevalence of food allergy training, training topics, and practices related to food allergies, CDC's Environmental Health Specialists Network (EHS-Net), a collaborative forum of federal agencies and state and local health departments with six sites, interviewed personnel at 278 restaurants. Fewer than half of the 277 restaurant managers (44.4%), 211 food workers (40.8%), and 156 servers (33.3%) interviewed reported receiving food allergy training. Among those who reported receiving training, topics commonly included the major food allergens and what to do if a customer has a food allergy. Although most restaurants had ingredient lists for at least some menu items, few had separate equipment or areas designated for the preparation of allergen-free food. Restaurants can reduce the risk for allergic reactions among patrons by providing food allergy training for personnel and ingredient lists for all menu items and by dedicating equipment and areas specifically for preparing allergen-free food.

Within each of the six EHS-Net sites (California, Minnesota, New York, New York City, Rhode Island, and Tennessee), data collectors chose a convenient geographic area, based on reasonable travel distance, in which to survey restaurants by telephone to determine their study eligibility and request participation. Within each geographic area, a random sample of restaurants was selected using statistical software. Restaurants were defined as facilities that prepare and serve food or beverages to customers and are not food carts, mobile food units, temporary food stands, or caterers, and are not located in supermarkets or institutions. Only restaurants with an English-speaking manager were eligible to be included in the study. Data collectors assessed approximately 50 restaurants in each of the sites. Data were collected during January 2014–February 2015.

After obtaining permission from the restaurant manager, data collectors conducted an on-site interview with a worker who had authority over the kitchen (manager), a worker who primarily prepared or cooked food (food worker), and a worker who primarily took orders or served food to customers (server). To increase participation and cooperation, data collectors asked the manager to select the English-speaking food worker and server to be interviewed. Data collectors interviewed all three personnel groups about food allergy training they had received while working at their current restaurant, including training topics covered (e.g., what are the major food allergens?). Managers also were asked whether the restaurant had ingredient lists for menu items accessible to the staff, customers, or both and whether special equipment or resources were dedicated to serving customers with food allergies (i.e., does this restaurant have a special area in the kitchen for making allergen-free food?).

Among the 1,307 restaurants contacted for participation in the study, 852 met the study eligibility criteria, and 278 (32.6%) of those agreed to participate; 58 restaurants were excluded because they did not have an English-speaking manager, and another 177 were excluded because they did not meet the restaurant definition for EHS-Net inclusion. Data on restaurant, manager, food worker, and server characteristics have been published previously.[4] Among 277 managers, 123 (44.4%) reported that they had received training on food allergies while working at their respective restaurants (Table 1). Manager food allergy trainings most often covered how to prevent cross-contact (the inadvertent transfer of allergens from food, equipment, or surfaces containing an allergen to a food that does not contain the allergen) (96.7%); the major food allergens (milk, eggs, fish, shellfish, tree nuts, peanuts, wheat, and soybeans) (92.7%); and what to do if a customer has a food allergy (80.5%).

Among 211 food workers, 86 (40.8%) reported receiving food allergy training while working at their respective restaurants. Food worker food allergy trainings most often covered how to prevent cross-contact (98.8%), what to do if a customer has a food allergy (90.7%), and the major food allergens (86.0%).

Among 156 servers, 52 (33.3%) reported receiving food allergy training while working at their respective restaurants. Server food allergy trainings most often covered what to do if a customer has a food allergy (94.2%), the major food allergens (86.5%), and how to prevent cross-contact (84.6%). Across all three restaurant personnel groups, fewer participants reported that training covered menu items with food allergens (69.1% of managers, 76.7% of food workers, and 78.8% of servers), symptoms of an allergic reaction (67.5% of managers, 62.8% of food workers, and 61.5% of servers), and what to do if a customer has a bad allergic reaction (e.g., difficulty breathing) (64.2% of managers, 69.8% of food workers, and 73.1% of servers) (Table 1).

Among managers, 55.2% reported that their restaurants had ingredient lists or recipes for all or most menu items, 18.4% reported ingredient lists for some menu items, and 25.3% reported having no lists (Table 2). Among managers, 19.1% reported that their restaurants had a dedicated set of utensils or equipment for making allergen-free food (a meal free of the allergen to which a patron is allergic), and 78.0% reported no dedicated set of utensils or equipment. Few managers reported that their restaurant had a special area in the kitchen for preparing allergen-free food (7.6%), a special fryer for cooking allergen-free food (10.3%), or a special pick-up area for customers with food allergies (7.2%).

Have you had training on food allergies while working at this restaurant?

Yes

123 (44.4)

86 (40.8)

52 (33.3)

No

152 (54.9)

123 (58.3)

103 (66.0)

Unsure

2 (0.7)

2 (1.0)

1 (0.6)

Did your training cover§

How to prevent cross-contact from food allergens to other foods?

119 (96.7)

85 (98.8)

44 (84.6)

The most common, or major, food allergens?

114 (92.7)

74 (86.0)

45 (86.5)

What to do if a customer says they have a food allergy?

99 (80.5)

78 (90.7)

49 (94.2)

The menu items with food allergens in this restaurant?

85 (69.1)

66 (76.7)

41 (78.8)

The symptoms of an allergic reaction?

83 (67.5)

54 (62.8)

32 (61.5)

What to do if a customer has a bad food allergic reaction (e.g., trouble breathing)?

79 (64.2)

60 (69.8)

38 (73.1)

*Percentages might not sum to 100% because of rounding.†California, Minnesota, New York, New York City, Rhode Island, and Tennessee.§Denominators for percentages are the number of respondents in each group who said they had received training: 123 managers, 86 food workers, and 52 servers.

Sidebar

Sidebar

Summary

What is already known about this topic?

Food allergies affect an estimated 15 million persons in the United States and are responsible for approximately 30,000 emergency department visits and 150–200 deaths each year. Nearly half of fatal food allergy reactions over a 13-year period were caused by food from a restaurant or other food service establishment.

What is added by this report?

Fewer than half of members of the restaurant staffs surveyed in 278 restaurants had received training on food allergies. Topics frequently covered in the trainings were identifying the major food allergens, what to do if a customer has a food allergy, and how to prevent cross-contact of allergens. Although most restaurants have ingredient lists or recipes for at least some menu items, few have separate equipment or areas designated specifically for the preparation of allergen-free food.

What are the implications for public health practice?

It is important for restaurants to provide food allergy training for staff members and ensure that the training covers critical information. Restaurants can dedicate equipment and create separate areas that are specifically designated for preparing meals for customers with food allergies. Adopting these practices can reduce the risk for an allergic reaction among patrons.